Provider Demographics
NPI:1841371127
Name:FRED, CAROL ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:FRED
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 N MARENGO AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1764
Mailing Address - Country:US
Mailing Address - Phone:626-794-1120
Mailing Address - Fax:626-316-6650
Practice Address - Street 1:95 N MARENGO AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1764
Practice Address - Country:US
Practice Address - Phone:626-794-1120
Practice Address - Fax:626-316-6650
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS44211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW4421Medicare ID - Type Unspecified